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34300004919811
Universiteit Vrystaat
By
TECHNICIAN CERTIFICATE AND THE EMERGENCY MEDICAL CARE PROFESSIONAL DEGREE
CRAIG VINCENT-LAMBERT
Thesis submitted in fulfilment of the requirements for the degree Philosophiae Doctor in Health Professions Education
Ph.D. HPE
in the
. DIVISION HEALTH SCIENCES EDUCATION
FACULTY OF HEALTH SCIENCES
UNIVERSITY OF THE FREE STATE
BLOEMFONTEIN
15 NOVEMBER 2011
PROMOTER: Dr l. Bezuidenhout
1 B JUN 2013
8LOE~{~fC•..~'T.~.~
DECLARATION
I hereby declare that the work submitted here is the result of my own independent investigation. Where help was sought, it was acknowledged. I further declare that this work is submitted for the first time at this university/faculty towards a Philosphiae Doctor degree in Higher Education studies and that it has never been submitted to any other university / faculty for the purpose of obtaining a degree.
Craig Vincent-Lambert
7/11/2011
NAME OF STUDENT DATE
I hereby cede copyright of this product in favour of the University of the Free State.
Craig Vincent-Lambert
7/11/2011
DEDICATION
I dedicate this thesis to all our emergency care educators and operational personnel in South Africa; despite the fact that your efforts are not always adequately ecknowledqed, it is you who are the ones people turn to in their hour of need.
ACKNOWLEDGEMENTS
I wish to express my sincere thanks and appreciation to the following:
• My promoter, Dr Johan Bezuidenhout and co-promoter Prof. M.V. Jansen van Vuuren from the University of the Free State for their support, patience and guidance during the course of this study.
• My wife Tracey and children Matthew and Ashleigh; I know we cannot get back the time I sacrificed to complete this study. Without your love and support, none of this would have been possible.
• My Parents, Neil and Anne, for their ongoing and continued support for my various studies, including this Ph.D.
• The focus group members and Delphi panellists - you all know who you are; without your participation, this study would not have been possible. • The Departments of Emergency Medical Care and Rescue at the Durban
University of Technology and Cape Peninsula University of Technology for sharing with me their study guides and learning material.
• Elaine Swanepoel and the staff of the Department of Anatomy and
,-Physiology at the University of Johannesburg for sharing with me their study guides and learning materials.
• To Prof. Andre Swart, Dean of the Faculty of Health Sciences at the University of Johannesburg for his mentorship, support and guidance over many years.
• To Mr Christo Fourie and Ms Michelle de Klerk for language editing and checking of the references consulted.
Page
I
CHAPTER 1:
ORIENTATION TO THE STUDY
1.1
1.2
1.2.1
INTRODUCTION
BACKGROUND TO THE RESEARCH PROBLEM
Emergency Medical Services
1.2.2 Emergency Care Training and Education in South Africa
1.2.3 Academic Developments
1.2.4 Challenges within the system of emergency care education and training
1.2.5 1.2.6 1.3 1.4 1.5
1.5.1
1.5.21.5.3
Recent developments Alignment of qualificationsPROBLEM STATEMENT AND RESEARCH QUESTIONS
SIMILAR STUDIES ON EMERGENCY CARE EDUCATION
OVERALL GOAL, AIM AND OBJECTIVES OF THE STUDY
Overall goal of the study
Aim of the study
Objectives of the study
1
1
2
2
4 45
6
7 911
1111
11CHAPTER 2: EMERGENCY CARE EDUCATION AND TRAINING
1.6
DEMARCATION OF THE FIELD AND SCOPE OF THESTUDY
13
1.7
THE FOCUS GROUP AND DELPHI PARTICIPANTS14
1.8
THE RESEARCHER14
1.9
SIGNIFICANCE AND VALUE OF THE STUDY15
1.10
RESEARCH DESIGN AND METHODS15
1.10.1
Design of the study15
1.10.2
Methods of the investigation and flow of the study16
1.11
IMPLEMENTATION OF THE FINDINGS20
1.12
ARRANGEMENT OF THE REPORT20
1.13
CONCLUSION22
2.1
INTRODUCTION23
2.2
HISTORY OF PARAMEDICS23
2.3
EMERGENCY CARE EDUCATION AND TRAINING INSOUTH AFRICA
27
2.3.1
Problems associated with the short-course system27
2.3.2
Recent developments30
2.3.3
Uniqueness of the South African Model of Emergency32
2.4 MID LEVEL WORKERS (MLWs)
33
2.4.1 Examples of mid-level workers internationally35
2.4.2 Mid-Level health workers in Africa
35
2.5
VOCATIONAL EDUCATION, MOTIVATION AND THEDESIRE TO STUDY FURTHER
36
2.6 ARTICULATION BETWEEN THE EMERGENCY CARE
TECHNICIAN (ECT) AND THE BACHELOR OF HEALTH SCIENCE DEGREE IN EMERGENCY MEDICAL CARE
(BHS EMC)
38
2.7
ANTICIPATED CHALLENGES RELATING TOARTICULATION BETWEEN THE ECT AND THE B EMC
QUALIFICATIONS 39
2.8 ANALYSIS AND THE COMPARISON OF THE
EMERGENCY CARE TECHNICIAN PROGRAMME TO
THE BACHELOR OF HEALTH SCIENCES DEGREE IN
EMERGENCYMEDICAL CARE
40
2.8.1 Introduction
40
2.8.2 Criteria for the comparison of the ECT and BHS EMC
Qua
I
ifications 412.8.2.1
Qualificationnamesandtitles
42
2.8.2.2
Standardgeneratingbodies(SGB)s
44
2.8.2.3
Educationandtrainingqualityassurors(ETQA)s
44
2.8.2.4
Providers
45
2.8.2.5
Qualificationtypes
47
2.8.2.6
Fieldsanddesignators
48
2.8.2.7
Subfields and qualifiers
49
2.8.2.8
ABETbands
49
2.8.2.9
Credits
SO
2.8.2.10
NQFlevels
51
2.8.2.11
Qualification class
54
2.8.2.12
Purpose rationale of the ECTand B EMCqualifications
SS
2.8.2.13
Thepurpose of the Emergency Care Technician (ECT)
qualification
56
2.8.2.14
The purpose of the Bachelor Health Sciences Degree
qualification
56
2.8.2.15
Rationale for the ECTqualification
58
2.8.2.16
Rationale for the BHS EMCqualification
59
2.8.2.17
Benefit to the holders of the ECTqualification
60
2.8.2.18
Benefit to the holders of the B EMCqualification
60
2.8.2.19
Benefit of the ECT qualification
to the emergency
care profession
61
2.8.2.20
Benefit of the B EMC qualification to the emergency
care profession
62
2.8.2.21
Benefit of the ECTqualification to society
63
2.8.2.22
Benefit of the B EMCqualification to society
63
2.8.2.23
Recognition of prior learning
63
2.8.2.24
Assessment of prior learning
66
CHAPTER 3: RESEARCH METHODS AND PROCEDURES
2.8.2.26
Qualification rules
70
2.8.2.27
Exit level outcomes (ELO)s
70
2.8.2.28
Presence of electives
74
2.8.2.29
International comparability
75
2.8.2.30
Teaching, learning and assessment practices
76
2.8.2.31
Articulation options
77
2.9
CONCLUSION77
3.1
INTRODUCTION79
3.2
THEORETICAL PERSPECTIVES ON THE RESEARCHDESIGN
79
3.2.1
Theory building79
3.2.2
Types of methods81
3.2.3
The research design in this study82
3.3
RESEARCH METHODS AND PROCEDURES83
3.3.1
Literature review84
3.3.2
Document analysis85
843.3.3
The focus group discussion86
3.3.3.1
Theoretical aspects
86
3.3.3.3
Sample selection
87
3.3.3.4
Description of sample
88
3.3.3.5
Thepilot study
88
3.3.3.6
Data gathering
89
3.3.3.7
Data analysis
89
3.3.3.8
Data interpretation
89
3.3.4
The Delphi Technique90
3.3.4.1
Theoretical aspects
90
3.3.4.2
TheDelphi questionnaire in this study
91
3.3.4.3
Sample selection
92
3.3.4.4
Description of sample
92
3.3.4.5
Pilot study
93
3.3.4.6
Data gathering
93
3.3.4.7
Data analysis
93
3.3.4.8
Data interpretation
94
3.4
TRUSTWORTHINESS95
3.5
ETHICAL CONSIDERATIONS97
3.6
CONCLUSION97
I
CHAPTER 4:
THE FOCUS GROUP INTERVIEW
4.1 INTRODUCTION
98
4.2 THE FOCUSGROUPINTERVIEW
98
4.2.1 Results and findings of the focus group discussion
99
4.2.1.1
Focusarea one - Theneed for articulation?
1004.2.1.2
Focus area two - How well does the ECTprogramme
prepare the graduate for further study?
1024.2.1.3
Focus area three - Structure of the ECT and B EMC
programmes
1044.2.1.4
Focus area four - The possible need for a bridging
programme
1104.2.1.5
Focusarea five - Potential challenges
1124.3 CONCLUSION 113
I
CHAPTER S:
THE DELPHI QUESTIONNAIRE
5.1 INTRODUCTION 115
5.2 THE PARTICIPANTS 115
5.3 CLARIFYING THE FOCUSOF THE QUESTIONNAIRE 118
5.4 PROCEDUREFOR ADMINISTRATION OF THE DELPHI
5.5 FORMAT OF THE QUESTIONNAIRE AND
PRESENTATIONOF RESPONSES 119
5.5.1 Format of the questionnaire 119
5.5.2 Analysis and presentation of responses 120
5.6 RESPONSESTO SECTIONA 122
5.6.1 The desire for an increased scope of practice 122
5.6.2 Desire for promotion 123
5.6.3 The role and function of the ECTin the service 123
5.6.4 Link between lack of recognition and desire to study
further 124
5.6.5 Desire for the employer for ECTsto study further 125
5.6.6 The number of ECTswho would wish to study further 125
5.6.7 Sustained demand for articulation 126
5.6.8 Desire for knowledge and insight vs. desire for
increased scope 127
5.6.9 Summary 127
5.7 RESPONSESTO SECTION B 128
5.7.1 Primary function of the ECTprogramme 128
5.7.2 Ability of ECT graduates to cope with University
degree studies 129
5.7.3 Importance of the ECTs ability to become
self-directed learner 130
5.7.5
Ability of graduatesfrom the ECTprogrammeto cope
with degreestudies
131
5.7.6
Point
of
entry
into
the
Professional Degree
programme
132
5.7.7
Sciencecomponentof the ECTprogramme
132
5.7.8
Diagnosticabilities of ECTgraduates
133
5.7.9
Levelof Anatomy in the ECTprogramme
134
5.7.10
Levelof Physiologyin the ECTprogramme
134
5.7.11
Levelof EmergencyCarein the ECTprogramme
135
5.7.12
Clinical skills and scope of practice in the ECT
programme
136
5.7.13
Clinicallearning componentof the ECTprogramme
136
5.7.14
The high angle rescue components of the
ECT
programme
137
5.7.15
Standardof vehicle rescueon the ECTprogramme
138
5.7.16
Standard of fires search and rescue on the ECT
programme
138
5.7.17
ECTgraduates' knowledgeof professionalpractice
139
5.7.18
Exit-level credit allocation and structure of the ECT
programme
139
5.7.19
The maximum number of credits ECTsthat could be
awardedtoward the professionaldegreeprogramme
140
5.8 RESPONSESTO SECTION C
5.8.1 Format for the offering of bridging programme
5.8.2 The need for institutions to personalise the bridging programme
5.8.3 A work period before articulation into the degree programme
5.8.4 The bridging programme may be undertaken whilst working
5.8.5 Point of entry and aim of the bridging programme
5.8.6 Completion of the bridging programme should be mandatory for ECTs wishing to enjoy advance placement within the degree programme
5.8.7 Modules in the bridging programme should be credit bearing 5.8.8 Summary
5.9
RESPONSESTO SECTION D 5.10 RESPONSESTO SECTION E 5.11 RESPONSESTO SECTION F5.12
RESPONSESTO SECTION G 5.13 CONCLUSION 141 141 142 143 144 144 145 145 146 148 160 188195
196
I
CHAPTER 6: A FRAMEWORK FOR ARTICULATION6.1 INTRODUCTION 197
6.2 ROUTES OF ENTRY INTO EMERGENCY CARE
QUALIFICATIONS 198
6.2.1 Entry for school-Ieavers 198
6.2.2 Entry into emergency care qualifications for existing
in-service staff 200
6.3 THE PROPOSEDFRAMEWORKFORARTICULATION 202
6.3.1 The starting point for articulation 204
6.3.2 A period of clinical experience prior to further study 204
6.3.3 Selection of ECTgraduates for articulation and further
study 206
6.3.4 A bridging programme to assist ECT graduates in gaining advanced placement in the professional
degree programme 207
6.3.5 Granting of academic credit and/or Recognition of Prior Learning for modules in the professional degree
programme 209
6.3.6 Successful completion of the bridging programme allows ECT graduates to register for and enter the
third year of the BHS EMCdegree directly 211
6.3.7 The researcher proposes two possibilities for
6.4 ENROLMENTPLANNING 213
6.5 SUPPORTFOR ECTsTO STUDY FULL TIME 213
6.6 POTENTIAL ROLL-OUT PLAN 214
6.7 CONCLUSION 219
CHAPTER7: SUMMARY, RECOMMENDATIONSAND CONCLUSION
7.1 INTRODUCTION 220
7.2 SUMMARY 220
7.3 VALUE AND UNIQUE CONTRIBUTION
CHALLENGESAND LIMITATIONS
221
7.4 223
7.4.1 Limited published literature in the area of
investigation 223
7.4.2 Ongoing developments during the research period 223
7.4.3 Limited pool of experts for the focus group and Delphi 224
7.4.4 The length of the Delphi questionnaire 224
7.5 RECOMMENDATIONS 225
7.5.1 Introduction 225
7.5.2 Implementation of the framework 225
7.5.3 Enrolment planning 226
7.5.4 Funding for the Framework 226
7.5.6 Information sharing and marketing 227
7.5.7 Support for ECTs within the Emergency Medical
Services 227
7.5.7.1 Provision of suitable equipment 227
7.5.7.2 Clinical Governance and Mentoring 228
7.5.7.3 Continuing Professional Development 228
7.5.7.4 Introduction and integration with existing staff 228
7.6 CONCLUSION 230 BIBLIOGRAPHY 231 APPENDIX 1 243 APPENDIX 2 247 APPENDIX 3 250 APPENDIX4 253 APPENDIX 5 256 APPENDIX 6 260 APPENDIX 7 261 APPENDIX8 262
Figure 1.1:
Schematic overview of the study
19
LIST OF FIGURES
Figure 3.1:
Linear nature of the exploratory
mixed-method design used in this
study
Schematic outline of the sequenceof
the three research methods
Academic access pathways for school
leavers
entering
emergency
care
qualifications
199
82
Figure 3.2:
84
Figure 6.1:
Figure 6.2:
Academic access pathways for
in-service personnel who wish to obtain
higher education qualifications
201
Figure 6.3:
Framework for articulation between
the
emergency
care
technician
certificate
and
the
professional
degree in emergency medical care
203
Figure 6.4:
The two-year ECTqualification
204
Figure 6.5:
Period of clinical work post
-graduation prior to further study
205
Figure 6.6:
Point at which ECT graduates may
apply
to
enter
the
bridging
programme
206
Figure 6.8:
Figure 6.9:
Table 2.1:
Table 2.2:
Table 5.1
RPL and credit awarded for modules
within the first and second years of
the B EMCdegree
Registration and entry into the B EMC
degree
LIST OFTABLES
The lO-level NQF
Abbreviations for RPLInternationally
The Delphi panel member
209
211
52
64
116
*
B EMC and BHS EMC both refer to the same four-year qualification, and at the time of writing the two Abbreviations were synonymous and could be used interchangeably_ AEA: BAA: *B EMC: *BHS EMC: CCA: CHE: DoE: Eer: ETQA HE: HEI: HEQF: HPCSA: MLW: NDoH: NQF: RPL: SAQA: SGB: UoT:Ambulance Emergency Assistant Basic Ambulance Assistant
Bachelor Degree in Emergency Medical Care
Bachelor of Health Sciences Degree in Emergency Medical Care Critical Care Assistant
Council for Higher Education Department of Education Emergency Care Technician
Education and Training Quality Assuror Higher Education
Higher Education Institution
Higher Education Qualifications Framework Health Professions Council of South Africa Mid-Level Worker
National Department of Health National Qualifications Framework Recognition of Prior Learning
South African Qualifications Authority Standard Generating Body
Keyterms: Recognition of Prior Learning; articulation, Mid-Level-Worker, Career-pathing; Academic- Architecture
The need to comply with the requirements of the SAQA Act necessitated a review of emergency care education and training in South Africa. The review and restructuring led to the creation of a formal two-year, 240-credit NQF level 5 Emergency Medical Care Technician (ECT) Qualification. The NDoH views the ECT programme as the "Mid-Level Worker" equivalent for the Emergency Care Profession. At the Higher Education level, the existing three-year National Diploma and one-year B Tech Programmes were collapsed to form a single four-year, 480-credit, NQF level 8 Professional Bachelor of Health Sciences Degree in Emergency Medical Care (B EMC).
After the establishment of the two-year ECT and four-year B EMC programmes, the next challenge faced by the HPCSA, educators and educational providers within the emergency care field became that of facilitating articulation between the two qualifications. This study aimed to critically analyse and compare the two-year ECT qualification with the four-year professional B EMC degree in order to design a framework and bridging programme that may support and guide articulation between the two qualifications.
An expository, retrospective analysis of existing documentation was followed by a focus group discussion with educators in the field in order to identify and explore potential obstacles and challenges with regard to articulation between the ECT and the B EMC qualifications. Finally, a detailed Delphi Questionnaire was sent to selected expert panel members.
The study highlights a strong desire for articulation and academic progression within the emergency care profession. Similarities and substantial differences were identified in the scope, level and depth of knowledge of the ECT and B
EMC qualifications. A framework was designed that includes a bridging programme to provide ECT graduates with the necessary knowledge, skills and insights required to enter directly into the third year of the Emergency Medical Care Degree.
Sleutelterme: Erkenning van vooraf leer; artikulasie; Middelvlak werkers; Beroepsrigting; Akademiese Argitektuur
Die noodsaak om aan die vereistes van SAKO-wetgewing te voldoen, het fn hersiening van nooddiensonderrig en -opleiding in Suid-Afrika teweeggebring. Die hersiening en herstrukturering het tot die daarstelling van fn formele twee jaar, 240-krediet, NKR vlak 5 Noodgeneeskunde Tegnikus (Emergency Medical Care Technician (ECT)) kwalifikasie gelei. Die NDvG beskou die ECT-program as die "Middelvlakwerker" ekwivalent vir die Noodgeneeskundeprofessie. Op Hoër Onderwysvlak is die bestaande drie jaar Nasionale Diploma en die een jaar B Tech-programme saamgevoeg om die enkele vier jaar 480-krediet, NKR vlak 8,
Professionele Baccalaureus in Gesondheidswetenskappe Graad in Noodgeneeskunde (Professional Bachelor of Health Sciences Degree in Emergency Medical Care) (B EMC)) te skep.
Nadat die twee jaar ECT- en die vier jaar B EMC-programme tot stand gebring is, was die volgende uitdaging vir die GBRSA, onderwyskundiges en onderwysverskaffers op die noodgeneeskundeterrein om artikulasie tussen die twee kwalifikasies te fasiliteer. Hierdie studie stel dit ten doelom die twee jaar ECT-kwalifikasie en die vier jaar professionele B EMC-graad krities te analiseer en te vergelyk om sodoende fn raamwerk en oorbruggingsprogram te ontwerp wat artikulasie tussen die twee kwalifikasies kan rig en steun.
fn Verklarende, retrospektiewe analise van bestaande dokumentasie is opgevolg met fn fokusgroepbespreking wat onderwyskundiges in die veld betrek het om potensiële struikelblokke en uitdagings ten opsigte van artikulasie tussen die ECT- en B EMC-kwalifikasies te identifiseer en te ondersoek. Laastens is 'n uitvoerige Delphi-vraelys aan gekose deskundige paneellede gestuur.
Die studie beklemtoon fn sterk begeerte na artikulasie en akademiese vooruitgang in die nooddiensprofessie. Ooreenkomste en wesenlike verskille is identifiseer ten opsigte van die omvang, vlak en kennis van die ECT- en B EMC-kwalifikasies. fn Raamwerk is ontwerp wat fn oorbruggingsprogram insluit om ECT-gegradueerdes van die nodige kennis, vaardighede en insigte te voorsien om hulle in staat te stelom onmiddellik die derde jaar van die Gesondheidswetenskappe Graad in Noodgeneeskunde (Emergency Medical Care Degree) te betree.
A FRAMEWORK FOR ARTICULATION
BETWEEN THE EMERGENCY CARE
TECHNICIAN
CERTIFICATE
AND
THE EMERGENCY
MEDICAL CARE
PROFESSIONAL
DEGREE
CHAPTER 1
ORIENTATION
TO THE STUDY
1.1
INTRODUCTION
In this piece of research, an in-depth study was done by the researcher with a view to designing a framework that could guide and facilitate articulation between two academic programmes within the emergency care profession. This first chapter aims to provide the context of and background and to the study. The chapter begins by describing the background to the research problem within the context of emergency care education and training internationally and locally; thereafter, the research questions, problem statement, scope, overall goal, aim and research design are discussed. Finally, Chapter 1 concludes by providing an outline of this thesis and the chapters that are to follow.
1.2
BACKGROUND TO THE RESEARCH PROBLEM
This study took place within the field of pre-hospital emergency care education and training in South Africa. Emergency care education and training has recently been aligned with the requirements of the South African Qualifications (SAQA) Act and the National Qualifications Framework (NQF) (HPCSA 2005: I-S). The alignment necessitated a review of education and training programmes within the emergency care profession as a whole. The following section aims to orientate and place the study within the context of emergency care education and training in South Africa.
1.2.1 Emergency Medical Services
Emergency care worldwide has come to form an essential and important component of a country's health care system (Arnold 1999:97-103). Emergency Medical Services (EMS) systems and structures, although fundamentally similar, vary from country to country with respect to the level of education and training provided to EMSworkers.
Logically, differences in levels of education and training lead to differences in medical scopes of practice and the professional status of EMS personnel. In some countries emergency care personnel are still not viewed as true medical professionals as they continue to function with little more than basic first-aid training. In certain EMS systems the provision of emergency care and the transportation of ill and injured persons to hospital is viewed, not as a separate profession, but rather as an add-on to a primary vocation such as law enforcement, or fire fighting (EMS Insider 2007: 1-12).
In such cases, the EMS system normally provides only basic life-support interventions within the pre-hospital setting and the focus is more on rapidly transporting the patient to a receiving hospital, as opposed to providing an advanced level of care in the pre-hospital environment. On the opposite end of the spectrum are EMS systems that aim to literally "bring the hospital to the patient". Such EMS systems employ a number of highly trained and clinically skilled personnel such as doctors, nurses, emergency care practitioners and advanced life-support paramedics (Platz, Bey & Walter 2003:203-210).
1.2.2 Emergency Care Education and Training in South Africa
Prior to 1980 there were no professional qualifications or a professional board for professional emergency care providers; emergency care training was fragmented and varied from province to province (RSA NDoH 2011). A number
of standardised short courses were introduced in 1985. Namely a three-week Basic Ambulance Attendant (BAA), an eight-week Ambulance Emergency Attendant (AEA) and a four-month Critical Care Assistant (CCA) course (HPCSA
1999a, b, c).
The BAA, AEA and CCA short courses were initially offered as a form of in-service training by the Provincial Ambulance Training Colleges (ATCs). The primary focus of these short courses was on clinical skills training. The scope of practice and functioning of short-course graduates were linked to rigidly defined clinical protocols with clinical governance being provided by Medical Doctors. The need, therefore, existed for formal Higher Education (HE) qualifications, which would be recognised, regulated and registered by the Health Professions Council of South Africa as a statutory (HPCSA2006:1-3).
The first such qualification was a three-year National Diploma in Ambulance and Emergency Technology (N. Dip AET) introduced in 1987. This three-year full-time higher education qualification would empower graduates to not only provide an appropriate standard of clinical care, but also through instilling an appreciation for research and professional academic development grow, nurture and guide the profession. From 2003 onwards a Bachelor of Technology Degree in Emergency Medical Care could be obtained, by completing an additional two years of part-time study, after obtaining the undergraduate three-year National Diploma qualification (RSA NDoH 2011) (SAQA 2009c:1).
It was acknowledged that the HE programmes would take some time to become established. The small number of HE institutions offering the three-year diploma programme led to a limited number of tertiary graduates being produced initially. This meant that output from the HE programmes could not rapidly address the immediate needs of the public. For this reason the short courses continued to be offered in tandem with the higher education offerings; the idea was that as soon as the HE programmes became established and started producing graduates short course training would be phased out.
Already qualified short-course graduates within the system could then be afforded an opportunity, through Recognition of Prior Learning (RPL) and in-service study, to attain the HE qualifications.
1.2.3 Academic developments
Apart from the four-month CCA course, which was extended to include an additional five months of clinical roadwork, the short courses remained relatively unchanged since their inception. In contrast, at the Universities the HE programmes continued to evolve and improve via a number of extensive re-curriculation efforts. From January 2005, Master's and Doctoral programmes are now also available to tertiary emergency care practitioner graduates (RSA NDoH 2011) (SAQA 2009c:1).
1.2.4 Challenges within the system of emergency care education and
training
As time went on, problems within short-course education and training structures began to surface in that the short courses were not phased out as initially intended (HPCSA 2005: 1-5). The private sector became significantly involved in short-course training, specifically in the offering of the three-week BAA course. This led to the HPCSA becoming increasingly inundated with requests from multiple role-players throughout the country all wishing to establish small colleges to offer short courses. With as many as 60 providers being accredited by 2005, numerous complaints began to be received by the HPCSA in relation to the quality of short-course training (HPCSA 2009:2). However, the sheer number of accredited providers meant that control over Emergency Care Education and Training had become virtually impossible. In addition to this, articulation between the short courses and the HE qualifications became increasingly difficult due to the following main reasons:
a) The academic architecture of the short courses was such that they could not be aligned to the National Qualifications Framework (NQF);
b) The academic architecture of the short course offerings was not SAQA compliant; and
c) The knowledge gap between short courses (which were non-credit-bearing) and the HE qualifications grew ever-wider (HPCSA2005: 1-2).
1.2.5 Recent developments
The need to comply with the requirements of the SAQA Act provided an opportunity for the entire system of emergency care education and training to be reviewed. The challenge lay in designing a SAQA and NQF compliant education and training structure, which would also meet with the needs of the National Department of Health (NDoH) and the Emergency Care Industry.
Central to the debate were important issues of lifelong learning, academic progression, career-pathing and placement as well as further professional development.
In order to align emergency care education and training to meet the above requirements, the HPCSA as Standard Generating Body (SGB) undertook a revision of the learning outcomes of the existing short courses. The result of this review and restructuring undertaken was the design of a formal, two-year, 240-credit NQF level 5 Emergency Medical Care Technician (ECT) Qualification (HPCSA 2011:7-8). The NDoH views this ECT programme as the "Mid-Level Worker" equivalent for the Emergency Care Profession. The ECT qualification was registered with SAQA and the first intake of students occurred in 2007 at Provincial Ambulance Training Colleges as well as selected Universities of Technology.
At the HE level, the three-year National Diploma and one-year B. Tech. Programme were collapsed and submitted to SAQA in the form of a single
four-year 480-credit, NQF level 8, Professional Bachelor of Emergency Medical Care (B.EMC.) degree. The B EMC allows for direct articulation into Master's and Doctoral Programmes. The Higher Education Institutions (HEls) offering Emergency Medical Care programmes are currently in the process of phasing out the three-year National Diploma qualification and implementing the four-year Professional degree.
More recently, the Council for Higher Education (CHE) and the Department of Higher Education & Training (DHET) have recommended to Higher Education Institutions the use of "Health Sciences" as a designator in the naming of the new four-year qualification, making the new name a Bachelor of Health Sciences in Emergency Medical Care (BHS EMC) (PBEC2010: 15).
1.2.6 Alignment of qualifications
Education and training for the emergency care profession in South Africa has recently been aligned to comply with the requirements of SAQA and the NQF. Currently, two tiers of education and training, both falling within the HE band of the NQF, are in place - the first being the two-year Emergency Care Technician (mid-level worker) programme and the second the four-year Professional Bachelor Degree. The necessary legislation has already been promulgated and registers are open at the HPCSA to accommodate graduates from these two programmes, providing them with professional registration and legislated scopes of practice (HPCSA2011:7-8).
The concept of a tiered approach with mid-level workers and practitioners is neither unique nor foreign to the health care professions. Although new in the South African Emergency Care environment, mid-level worker programmes have already been in place in a number of other countries (Dovlo 2004:4-9:0nline). If the current policies of the NDoH are to remain, mid-level health care workers will be introduced in most, if not all, of the registered professions, including medicine, radiography, and environmental health.
At this point it should also be noted that recent discussions between the NDoH and the HPCSA have introduced the idea that there may still be a need for a lower level of care - below that offered by the ECT as a mid-level worker, i.e. same form of Basic Life Support Provision (Naidoo 2011; RSA NDoH 2011). At the time of writing, no firm decisions had been taken regarding this. However, if such an idea finds favour with the regulatory authorities, we may see the emergence of a three-tiered approach to education and training in the emergency care profession. The first tier would then consist of a Basic Life Support (BlS) entry level/access qualification, followed by the Mid-level Worker qualification in the form of the Emergency Care Technician (ECT) and then finally the professional degree, Emergency Care Practitioner (ECP).
Regardless of whether or not the system remains two-tiered or changes through the addition of an additional BLS tier, there will remain a need for articulation between the mid-level worker ECT qualification and professional B EMC degree. It is this articulation pathway that forms the focus of this study throughout.
1.3 PROBLEM STATEMENT AND RESEARCH QUESTIONS
Having established the two-year ECT and four-year B EMC programmes, the next significant challenge faced by the HPCSA, educators and educational providers within the emergency care field was that of facilitating articulation between the two new qualifications.
As already mentioned, the researcher in this study aimed to design a framework that may support and guide articulation between the ECT qualification the professional B.EMC. degree in Emergency Medical Care. In order to do this a critical analysis and comparison of the two-year ECT qualification and four-year Bachelor degree had to be conducted. The main research questions therefore became:
1. How do the Eer and B EMCqualifications compare to and with each other in terms of general academic architecture, learning outcomes and educational modes of delivery?
2. What are the obstacles and challenges that educational managers are likely to face in articulating the mid-level worker Eer with the Professional B EMC Degree qualification?
3. What type of framework could address the identified obstacles and challenges related to articulation between the Eer and the Professional B EMCqualifications?
The first graduates from the Eer programmes entered the workplace during 2009. For this reason, it was important that a framework be developed soon which could facilitate and lend guidance to articulation between the two qualifications. Articulation is necessary if one is to cater for career-pathing, further professional development and lifelong learning within the profession.
As mentioned above, higher education qualifications in emergency care have only been in place for a few decades and post-graduate programmes are less than five years old. For this reason, there is currently very little locally published literature available on emergency care education and training.
In summary, the problem that needed to be addressed was that, prior to this study, there was no clearly defined educational framework informing and guiding academic articulation between the newly legislated and promulgated two-year, mid-level worker Emergency Care Technician (Eer) and the four-year B EMCprofessional degree qualifications within the emergency care profession.
1.4
SIMILAR STUDIES ON EMERGENCY CARE EDUCATION
The researcher made use of a number of electronic searches using Google Scholar, Pub Med, Science Direct and the University of Johannesburg's library search engines with the following key words and/or combinations thereof: "Emergency Care Technician", "Education", "Paramedic", "Training", "Mid-Level Health Workers", "Academic", "Articulation", "Learning". The results highlighted a lack of published literature on emergency care training in South Africa. A selection of the limited existing scholarly work in this is discussed below.
A 2007 study conducted by Lloyd Christopher at Durban University of Technology focusing on non-compliance of South paramedics with protocols and guidelines noted the fact that the quality of education and training of emergency care providers in South Africa needs to improve. Christopher also saw the introduction of the ECT mid-level worker programme and the BHS EMC as positive steps in further developing the profession locally. In addition, Christopher went on to specifically mention that a strategy needs to be designed that will allow for the development and progression of existing practitioners within the emergency care profession. Similar to the findings of the researcher in this study, Christopher also laments the dearth of local research and publications within the local emergency care profession (Christopher 2007:9-14).
A 2010 study conducted by Frauke Dillschnitter at the University of Johannesburg focused on determining of the potential impact that ECTsas mid-level workers may have on the provision of Advanced Life Support in the Sedibeng district. Dillschnitter also notes a lack of published literature on the ECT qualification (Dillschnitter 2010: 10) and concluded that ECTs may indeed have a significant impact on the provision of ALS care in the region (Dillschnitter 2010:38).
A 2011 study by Bernard Von Tonder, also at the University of Johannesburg looked at factors that may be used to predict the success of EeT students at two local emergency care training colleges. In his study Von Tonder emphasizes that there is a dire need for qualified emergency care personnel and furthermore that the EeT programme may be seen as an important first step to gain access to emergency care qualifications in the HE band (Von Tonder 2011 :8-12).
Aside from the limited literature described above, the researcher noted a virtual absence of prior studies focusing on emergency care education and training in South Africa. The lack of pre-existing published literature in this area is conceded to be a limitation in this study and indeed posed a significant challenge to the researcher when attempting to frame and contextualise the study.
For this reason the reader will see that several of the documents and references that ended up being used in this study are in the form of newsletters of the HPCSA,minutes of professional boards and education committee meetings, and draft polices from the National Department of Health, academic documentation from SAQA, the DoE and CHE. Generic educational literature and materials such as learning guides and course content documents from the Universities and Colleges offering the EeT and BHS EMC programmes also provided a significant and valuable source of raw data and baseline information required for this study.
In conclusion, prior to this study there was very limited published literature on emergency care education and training in South Africa. Aside from developing a framework for articulation, which remains the primary aim, this study also serves to make an additional contribution to expanding the limited body of published literature on local emergency care education and training in South Africa.
1.5 OVERALLGOAL,AIM AND OBJECTIVESOF THE STUDY
1.5.10verall
goal of the study
The overall goal of this study was to improve opportunities for emergency care education and training in South Africa. It is argued that this can ultimately contribute to improved patient care for the population. In addition, although focused on providing new, specific knowledge within the emergency care educational field, this study may also deepen the general insight and understanding of issues affecting the growth and continued professional development of mid-level workers and health care professionals in South Africa.
1.5.2 Aim of the study
The aim of this study was to design a framework for articulation between the Emergency Care Technician qualification and the Emergency Medical Care Professional Degree.
1.5.3 Objectives of the study
In pursuit of the aim stated above the following four main study objectives were identified:
1. By making use of a review of existing literature and document analysis;
to
Critically compare the two-year,
240-Credit
NQF 5 National
Certificate
Emergency
Care
Technology
Mid-level
worker
Qualification to and with the 480-Credit
NQF 8 Professional
Bachelor's Degree in Emergency Medical Care
in terms of general academic architecture, learning outcomes and educational modes of delivery. In view of creating a deeper insight and a thorough understanding of the similarities and differences between the two qualifications. It was felt that the outcomes of this critical comparisonwould provide the necessary foundational knowledge and starting point for subsequent research processes, i.e. the Focus Group Interview and Delphi Questionnaire
(cf.
Chapters 4 and 5).2. The knowledge and insights stemming from the literature review and critical comparison described above were then used to formulate an agenda for a focus group interview. The focus group interview was conducted with educators in the field aimed, in order to
identify and
explore
potential
obstacles
and
challenges
concerning
articulation between the ECT and the Professional BHS EMC
qualifications
(cf. Chapters 2 and 4).3. Using the data and insights obtained through the completion of the above two research objectives, a Questionnaire was designed and administered to experts in the field of emergency care service provision and education using the Delphi Technique. The Delphi questionnaire aimed
to elicit
consensusviews and opinions from experts in the field relating to
potential
solutions to
the
obstacles and
challenges
that
educational managers are likely to face in articulating the
mid-level worker
ECT with
the
Professional BHS EMC Degree
qualification
(cf. Chapters 2 and 4).4. By making use of the researcher's own knowledge, experience and expertise within the field, combined with the new knowledge and insights gained as a result of the above research processes the researcher would,
design a framework
that
may inform and guide academic
articulation
between the newly legislated and promulgated
national mid-level worker Emergency Care Technician (ECT) and
BHS
EMC
professional
degree
qualifications
within
the
emergency care profession (cf.
Chapter 6).1.6 DEMARCATION OF THE FIELD AND SCOPE OF THE STUDY
Melville and Goddard (2001:12-16) note that proper demarcation of the research problem and a well-defined scope and boundaries are important to provide focus and direction to any proposed research activity. The scope of this study is therefore limited to the design of the proposed framework to guide and facilitate the articulation and placement of Mid-Level EeT graduates from the respective training providers into the Professional Degree Programmes offered by the Universities.
The circulation of a bridging programme and implementation and piloting of such a framework and bridging including analysis of its functionality and impact, although important, lie beyond the scope of this particular study and may provide an excellent opportunity for further postdoctoral research into this area. Although beyond the scope of this study, valuable data were obtained from the Focus Group interviews and the Delphi questionnaire to guide the possible development of a curriculum. Data obtained also assisted the researcher to better understand the problem under investigation and to develop the required framework (cf. Chapter 5).
The findings of this study were applied within the field of Health Professions Education in developing a framework for articulation between the two programmes in the Emergency Care profession.
Due to the application of the study in the field of Emergency Care the study can be classified as being interdisciplinary, in "combining or involving two or more professions, technologies, departments, or the like, as in business or industry" (Infoplease 2011:0nline).
1.7 THE FOCUS GROUP AND DELPHI PARTICIPANTS
The participants in the focus group interview and Delphi questionnaire survey consisted of registered Emergency Care and Advanced Life Support practitioners who were involved in Lecturing, Academic Administration and Management, as well as Emergency Service Operations.
1.8 THE RESEARCHER
The researcher is a registered Emergency Care Practitioner with the HPCSAand is currently Head of the Department of Emergency Medical Care at the University of Johannesburg. The researcher is also a councillor of the HPCSA and member of the Professional Board for Emergency Care, where he serves as Chair of the Education Committee.
The researcher is a member of the Senate of the North West Provincial Emergency Medical and Rescue College. The researcher also serves as a member of the ministerial task team advising the Department of Health on matters relating to EMS training policy and development. Having spent the last 17 years as an academic involved in emergency care education and training, the researcher was instrumental in the development and accreditation of the ECT mid-level worker programmes.
The researcher noted the growth and establishment of the ECT programme and, having interacted with ECT students and graduates, realised a strong desire for recognition and further development. This prompted the research and him to apply his mind to the matter of articulation between the ECT programme and the four-year professional degree and how such articulation may be facilitated.
The study was conducted between June 2007 and December 2011, with the empirical research phase from 2009-2011.
1.9 SIGNIFICANCE AND VALUE OF THE STUDY
The value of this research study is that it supports the SAQA ethos of lifelong learning by creating a framework and pathway for Graduates from the EeT mid-level worker programmes to gain access to further study within the NQF that would subsequently assist them in the development of their careers within the health sector.
In addition, pathways and opportunities to uplift the general level of education of emergency care providers in South Africa will have a direct benefit to the public and patients that are seen. Finally, this study may also serve as a generic reference and useful guide for similar projects involving articulation and development of mid-level health workers in similar professional domains such as radiography, medicine, dentistry, physiotherapy and optometry.
1.10 RESEARCH DESIGN AND METHODS
1.10.1 Design of the study
This study included components of both quantitative and generic qualitative designs. A Quantitative approach was used via a Delphi questionnaire to gather, reflect on and refer to data, for purposes of defining quantifiable differences between the two qualifications as a basis for discussion and clarification.
Due to the very nature of the core objectives, it was felt that a purely quantitative or purely qualitative design would not have been able to fully address the research problem. For this reason an additional generic qualitative research design was also included in the form of a focus group interview (cf. 3.2.3). The researcher arrived at this paradigm or research approach that would best be addressing the research questions, inquiry and the deductive and inductive development of epistemology itself (Trafford & Leshem 2008:89-97).
This is supported by Leedy (1997:160-162) who notes that qualitative research designs best attempt to understand perceptions and views.
Both Creswell and Plano Clark (2007) and David and Sutton (2004) note that there are distinct advantages to the combination of qualitative and quantitative methods in a single study. They argue that the resulting mixture can strengthen the validity and reliability of findings (Creswell & Plano Clark 2007:5-12; David & Sutton 2004:44-46).
After considering the possibilities it was felt that for the purposes and depth of this doctoral study, three different empirical methodologies would need to be applied in order to gather sufficient valuable data for this study.
The researcher, having considered the above theories against the backdrop of the identified research questions and objectives of this study, decided that an exploratory, mixed-method research design would be most appropriate (Ivankova, Creswell & Plano Clark 1995:265). Within this design three distinct methodologies were applied to investigate and gather data, which were used to answer the research questions and achieve the identified objectives - ultimately leading to the accomplishment of the aim. The next section will outline these methods briefly.
1.10.2
Methods of the investigation and flow of the study
The first method consisted of a
review of literature
andexpository
retrospective analysis of existing documentation.
This was done by firstly selecting and identifying set criteria against which the two qualifications could be compared and analysed. After careful consideration, the researcher elected to use criteria similar to those used by the South African Qualifications Authority (SAQA) for the recording and registering of qualifications. A thorough engagement with the literature and a document analysis was needed as part of this study to show that the researcher has the scholarly depth and to contribute to the theoretical framework (cf. Chapter 2) (Trafford & Leshem 2008:73).It is argued that the selection of criteria used by SAQA was both logical and important as both the ECT and B EMC qualifications had been lodged with SAQA. Each of the criteria is unpacked, described and discussed within the context of existing literature on the ECT and B EMC programmes. The comparison and analysis and discussion of the two qualifications against the SAQA criteria produced many pages of valuable data and this is presented in Chapter 2. The information gathered during the literature review and document analysis was, together with the researcher's own experience as a health educator, used to formulate the focus group agenda and finally the statements for the Delphi Questionnaire.
As mentioned above, a focus group
interview
was conducted. The principle aim in all interviewing is obtaining valid and reliable information (Fielding 2003:11). The rationale behind the use of a focus group interview was that as additional information surfaced, it would be used to add to and refine the statements used for the final Delphi Questionnaire. The knowledge and insights stemming from the literature review and critical comparison described above were then used to formulate an agenda for a focus group interview. The focus group interview was conducted with educators in the field in order to identify and explore potential obstacles and challenges concerning to articulation between the ECT and the B EMCqualifications (cf. Chapter 4).Finally, a detailed Delphi Questionnaire was sent to 11 purposefully selected Delphi Panel members (cf. 5.2). The Delphi method involves collecting and distilling judgments of experts using a series of statements or questions (David & Sutton 2004:92-96). The Delphi method works particularly well when there is incomplete knowledge about a problem or phenomenon. The absence of existing literature on articulation between the relatively new ECT and B EMC programmes meant that the researcher had to look toward other sources of information and data. The engagement of educators and experts currently involved in the construction and offering of these programmes was seen as a
logical step in gathering data on the content and articulation between the two programmes.
After consensus was reached, the findings of the Delphi were utilised by the researcher to design a framework and propose outcomes for a bridging programme that could facilitate for articulation between the ECT and B EMC programmes. The framework is presented and discussed in Chapter 6.
A more detailed description of the population, sampling methods, data collection and techniques, data analysis, reporting and ethical consideration is provided in Chapter 4. A schematic overview of the study is provided in Figure 1.1.
~".·I
iiEvaluation Commlttett
, re
15
'e ...
''i••
rS·'TfEUi i ~
~..-~~'
....".J
Data analysis and interpretation
Delphi process
1
Data analysis and interpretation of the Delphi process
Development of the Framework for Articulation between the ECT and
theBHS EMC
1.11
IMPLEMENTATION OF THE FINDINGS
This report containing the findings of the research will be brought to the attention of the Professional Board for Emergency Care of the Health Professions Council of South Africa, the Departments of Emergency Medical Care at the Higher Education Institutions offering Emergency Care Education as well as Colleges involved in the offering of the ECT programme. It is the intention of the researcher to pilot the framework and bridging programme developed in this study, within his department at the University of Johannesburg, with graduates from ECT programmes in the region. Given that the researcher has a distinct role in various committees and in an advisory capacity at ministerial level, he can and will use the valuable data obtained from the Focus Group interview and Delphi questionnaire to guide and inform the various role-players.
In addition to the above, the research findings will be submitted to academic journals with a view to publication, as the researcher hopes to make a contribution to the improvement of health education. The research findings will also be presented at emergency care conferences and seminars.
1.12
ARRANGEMENT OF THE REPORT
The following section provides a brief outline of the study and layout of the thesis.
In this chapter (Chapter 1),
Orientation to the study,
the researcher provided the context and background to this study by providing a list of acronyms and definitions of generally used terms that are applicable to this study. Thereafter, the background to the problem, problem statement, scope, overall goal, and aim and research design were introduced.Chapter 2,
Emergency Care Education and
Training,
provides the theoretical orientation to the study and deals with a review of literature on Emergency Services Education and Training and the concept of mid-level health workers. The second part of the chapter contains an analysis and critical comparison of the ECT and BHS EMCqualifications.In Chapter 3,
Research design and methodology,
the research design and methods selected for this study are described and validated. These include a Focus Group Interview and Delphi questionnaire. The focus group interview focussed on identifying and exploring potential obstacles and challenges concerning to articulation between the ECT and the Professional BHS EMC qualifications. The Delphi technique was applied to obtain consensus opinions of experts on matters affecting articulation between the two programmes. The way in which the Delphi questionnaire was constructed and administered is also dealt with in Chapter 3, as are issues of validity, reliability and ethical considerations applicable to this study.Chapter 4,
The Focus Group
Interview;
describes the Focus Group Interview, and the analysis of the data gathered from the Focus Group Interview, before reporting and discussing the results and findings.Chapter 5,
The Delphi
survey; presents the analysis, findings and results ofthe Delphi process.
Chapter 6,
The Proposed Framework for the Articulation between the
Emergency Care Technician Certificate and Emergence Medical Care
Professional Degree,
begins by providing a description of suggested access pathways for school leavers and in-service personnel into the ECT and BHS EMC programmes. Following on from the discussion of entry and access pathways into the ECT and BHS EMCqualifications, the researcher presents, unpacks and describes the framework for articulation and its various components.The chapter concludes by presenting a proposed model for articulation and upgrading of in-service staff qualifications.
Chapter 7, Conclusions, recommendations and limitations of the study,
provides an overview of the study, together with a discussion on possible limitations of the study and is concluded by some recommendations.
1.13 CONCLUSION
This first chapter provides an orientation to the study, background to the problem, problem statement, scope, and overall goal and discussed aim together with a brief introduction to the research design and research methods. The chapter concludes by providing an outline of the thesis and the chapters to follow. The following chapter will provide the theoretical orientation and framework to the study and an analysis and critical comparison of the ECT and BHS EMCqualifications.
CHAPTER 2
EMERGENCY CARE EDUCATION AND TRAINING
2.1
INTRODUCTION
As explained in Chapter 1, this study aimed to investigate and describe how the two-year Emergency Care Technician (ECT) mid-level worker qualification compares to the four-year Professional degree in Emergency Medical Care (B EMC) for the purposes of designing a framework that may support articulation between these two qualifications.
A challenge faced by the researcher in terms of this study was that there was very little existing published literature on emergency care education and training in South Africa. This chapter begins by discussing the history of paramedics and paramedical training locally and abroad. In order to do this the researcher made use of an analysis of existing documentation both published and unpublished. The literature is further supplemented by a discussion of mid-level health workers internationally and in Africa, vocational education and the importance of lifelong learning and academic articulation, all of which constitute central themes applicable to this study.
Following on from the review of literature the chapter continues by providing a detailed in-depth critical documentary analysis and comparison of the structure of the ECT and EMCqualifications.
2.2
HISTORY OF PARAMEDICS
The word "paramedic" literally means "along-side medicine", a person whose job is it to assist and support doctors (The South African Oxford School Dictionary 1998:314). The need for a person specifically trained to provide immediate care to ill or injured patients in the pre-hospital setting was
identified many years ago during time of war. Injured soldiers on the front line were attended to by "medics" as opposed to doctors and surgeons who were seen as too valuable a commodity to risk placing directly in the front lines.
Early research into survival from traumatic events began to highlight the important link between rapid medical intervention and survival. The concept of the now universally recognised "golden hour" principle began to emerge. The "golden hour" was defined as the first 60 minutes post injury or insult. Injured
patients who received little or no medical intervention during this first hour were noted to be less likely to survive than those who did, even though both may have ultimately ended up in the same receiving facility. This understanding redirected efforts away from simply scooping up the patient and rushing them to hospital toward initiating emergency medical treatment prior to and during transport (Joseph 2002:75).
Whilst the above idea was well supported, there remained insufficient numbers of medical doctors to deploy with each unit. The solution lay in training none-medical personal and fellow soldiers to provide first aid in the field. Initially this training was rudimentary and focused mainly on the stemming of bleeding, splinting of fractures and simple first aid. However, as time went on, army medics became better trained and their scope of practice subsequently increased. Medics became recognised as a valuable human resource that could render care at the site of injury, stabilise patients and facilitate ongoing care until such time as they could be transported and handed over to a medical doctor at a field hospital or definite care facility.
The above concept was imported into the civilian non-combat environment and it became acknowledged and accepted that ambulance crews were able to do far more than simply rush ill and injured patients to hospital hoping they would be alive on arrival (Caroline 2008:1.5-1.9).
The training and scope of practice of ambulance personal differed vastly between different countries and even regions within the same country. Early on ambulance services were not always seen as fully evolved independent service, rather the operating of ambulances were placed under the control of other, more recognised departments within the civil service such as traffic, law enforcement or fire services (RSA NDoH 2011). Here staff and management within the various departments often saw the manning of ambulances as just an add-on or adjunct to their primary function.
In South Africa the development of the Emergency Medical Services followed a very similar pathway. In many of the urban areas ambulances were initially manned either by the municipal traffic department or by the local fire service staff. Although things have changed, the link between fire fighting, rescue and emergency care remains well established and there are still a number of large "combined" services who render all three functions both locally and abroad (Christopher 2007: 1-12).
In contrast to the combined service model a number of provinces within South Africa have subsequently removed the responsibility for providing emergency medical services from the local fire/law enforcement departments at municipal level. In such areas the rendering of emergency medical services now remains the direct responsibility of the Provincial Government under the umbrella of the National Department of Health (Christopher 2007:9).
Regardless of which department or sector provides the service, ultimately patients need to be attended to by ambulance crews on the vehicles dispatched to the incidents. The level of care provided by a service is thus determined by the level of education/training and subsequent scope of practice of the staff within their service.
Education and training for emergency care personnel differ vastly between different countries and EMS systems. Certain EMS systems, such as that seen
in France offer a doctor-based system with medical doctors responding on emergency vehicles to calls. In systems like this, pre-hospital clinical decision making and medical intervention is at an advanced level and remains the prerogative of the doctor on the vehicle and not the paramedic
per se,
although doctor-driven paramedics still play an important role in these systems in acting as an assistant to the senior doctor or clinician (Nikkanen, Pouges & Jacobs 1998:31, 116-120).At the other end of the spectrum are EMSsystems that operate with ambulance crews that have as little as three to four weeks of basic training. In these systems, clinical decision making, research and development, formulation of medical protocol and associated clinical governance are undertaken by medical doctors and not paramedics. In this type of model, paramedics are not usually viewed as independent clinicians or practitioners and subsequently their associated training is more technical in nature, with a strong focus on the following of medical protocol (Ramalanjaona 1998:31, 766-768).
The different EMS systems described above entails that personnel within these services will have different levels of training and/or education and subsequently they will be able to provide differing levels of patient care. Three main tiers of emergency care have become generally recognised locally and internationally. These levels are Basic Life Support (BLS), Intermediate Life Support (ILS) and Advanced Life Support (Christopher 2007:22).
It is also important to acknowledge that the scopes of practice, associated clinical skills and/or procedures that define the boundaries between Basic, Intermediate and Advanced Life Support remain ill-defined and subject to varied interpretation. The recent emergence of the Emergency Care Technician (ECT) as a mid-level health worker (MLW) programme for the local emergency care profession has and continues to generate heated debate as to whether ECT graduates can or should be considered as advanced life-support providers.
2.3 EMERGENCY CARE EDUCATION AND TRAINING IN SOUTH AFRICA
In South Africa, Emergency Medical Care and EMS systems became established in a similar fashion to that described above. EMS education and training in South Africa historically comprised a number of "short courses" offered alongside formal Higher Education (HE) diplomas and degrees. These short courses ranged from a four-week Basic Ambulance Attendant (BAA) Course and 12-week Ambulance Emergency Assistant (AEA) course and a nine-month Critical Care Assistance (CCA) course (HPCSA1999a, b, c).
The higher education qualifications consisted of a three-year National Diploma (N. Dip.) and an additional one-year post-graduate Bachelor (B. Tech.) Degree.
Three registers historically existed at the HPCSA to allow for professional registration. A Basic Life Support (BlS) register for BAA graduates, an Intermediate Life Support (IlS) Register for AEA graduates and an Advanced Life Support (ALS) register for CCA and N. Dip. Graduates (HPCSA 2011: Online). However, as time went on a number of problems with this model began to emerge.
2.3.1 Problems associated with the short-course system
During the 1990s and up to the present, the private sector became highly involved in short course training, specifically in the offering of the four-week BAA course. BAA training proved to be extremely lucrative with young people across the country being lured to private colleges on a promise of work, and then into paying large sums of money for the month-long BAA course. BAAs were being produced in massive numbers that far exceeded that required by the emergency services and National Department of Health (RSA NDoH 2011). This oversupply did not stop the HPCSAbecoming continuously inundated with
